What is the initial management for patients with heart failure with reduced ejection fraction (HFrEF)?

Initial Management of Heart Failure with Reduced Ejection Fraction (HFrEF)

The initial management of HFrEF should include quadruple therapy with SGLT2 inhibitors, beta-blockers, renin-angiotensin system inhibitors (preferably sacubitril/valsartan), and mineralocorticoid receptor antagonists to significantly reduce mortality and hospitalizations. 1

Medication Initiation Algorithm

First-Line Medications

1. SGLT2 inhibitors and MRAs:

   • Start first as they have minimal effect on blood pressure
   • SGLT2 inhibitors: Dapagliflozin 10mg daily or Empagliflozin 10mg daily
   • MRAs: Spironolactone 12.5-25mg daily or Eplerenone 25mg daily 2, 1

2. Beta-blockers (if heart rate >70 bpm):

   • Start with low dose and gradually up-titrate
   • Options include:
     • Bisoprolol: 1.25mg once daily, target 10mg once daily
     • Metoprolol succinate: 12.5-25mg once daily, target 200mg once daily
     • Carvedilol: 3.125mg twice daily, target 25-50mg twice daily 1
   • Selective β₁ receptor blockers (bisoprolol, metoprolol) may be preferred due to lesser BP-lowering effect 2

3. Renin-angiotensin system inhibitors:

   • Preferably sacubitril/valsartan (ARNI): Start with 49/51mg twice daily, target 97/103mg twice daily
   • If not tolerated, use ACE inhibitors:
     • Lisinopril: 2.5-5mg once daily, target 20-40mg once daily
     • Enalapril: 2.5mg twice daily, target 10-20mg once daily
     • Ramipril: 1.25-2.5mg once daily, target 10mg once daily
   • If ACE inhibitors contraindicated, use ARBs:
     • Candesartan: 4-8mg once daily, target 32mg once daily 2, 1

Special Considerations for Low Blood Pressure

For patients with low blood pressure:

• Start with SGLT2i and MRA first as they have minimal effect on BP
• Then add low-dose beta-blocker (if HR >70 bpm) or low-dose sacubitril/valsartan (50mg twice daily or even 25mg twice daily)
• Up-titrate gradually with small increments, one drug at a time 2
• If beta-blockers are not hemodynamically tolerated and patient is in sinus rhythm, consider ivabradine as an alternative 2
• For patients with atrial fibrillation and uncontrolled heart rate, digoxin may be used 2

Titration Strategy

• Up-titrate medications in small increments every 1-2 weeks
• Focus on one drug at a time
• Monitor closely for side effects
• Adjust diuretics according to volume status 2, 1

Device Therapy Considerations

• Consider cardiac resynchronization therapy (CRT) for patients with QRS duration ≥150 msec and LBBB morphology 1
• Consider implantable cardioverter-defibrillator (ICD) for patients with LVEF ≤35% despite ≥3 months of optimal medical therapy (with expected survival >1 year) 1

Lifestyle Modifications

• Regular physical activity with structured aerobic exercise program starting at low intensity 1
• Moderate sodium restriction to reduce fluid retention 1
• Daily weight monitoring with action plan for weight gain >2kg in 3 days 1
• Smoking cessation and limiting alcohol consumption to moderate intake 1

Common Pitfalls and Caveats

• Avoid abrupt discontinuation of beta-blockers as it can cause rebound ischemia and arrhythmias 1
• Avoid NSAIDs and COX-2 inhibitors in all heart failure patients due to increased risk of worsening heart failure 1
• Avoid thiazolidinediones (glitazones) due to increased risk of worsening heart failure 1
• Avoid combining ARB with ACE inhibitor and MRA due to increased risk of renal dysfunction and hyperkalemia 1
• Avoid diltiazem/verapamil in HFrEF patients as they increase risk of worsening heart failure 1
• Avoid excessive diuresis in patients without fluid overload as it can worsen symptoms by reducing preload excessively 1

Monitoring Parameters

• Blood pressure and heart rate
• Renal function and electrolytes
• Volume status
• Symptoms and functional capacity
• Medication adherence and side effects

By following this structured approach to medication initiation and titration, along with appropriate lifestyle modifications and monitoring, the management of HFrEF can significantly reduce mortality, hospitalizations, and improve quality of life for patients.